Premature Mortality and Causes of Death Among People With Epilepsy: A Nationwide Population-Based Incident Cohort Study

Epilepsy trends in Kazakhstan: A retrospective longitudinal study using data from unified national electronic health system 2014-2020

OBJECTIVE

This study is designed to estimate the epidemiology of epilepsy in Kazakhstan, using a large-scale administrative health database during 2014-2020.

METHODS

Using the Unified National Electronic Health System of Kazakhstan over a seven-year span, we explored incidence and prevalence rates, disability-adjusted life years (DALY), and all-cause mortality. Regression models using Cox proportional hazards were used to analyze the sociodemographic, mental, behavioral, and neurological factors affecting survival. Overall analyses were performed using STATA (V.16).

RESULTS

The total cohort comprised of 82,907 patients, with a significant increase in the incidence of epilepsy from 26.15 in 2014 to 88.80 in 2020 per 100,000 people. Similar trends were observed in the prevalence rates, which tripled from 26.06 in 2014 to 73.10 in 2020. While mortality rates fluctuated, the elderly and children had the greatest rates of 9.97 and 2.98 per 1000 person-years respectively. DALYs revealed a substantial disease burden, with 153,532 DALYs (824.5 per 100,000) being lost during the study period. A few comorbidities, such as cerebral palsy (adjusted hazard ratio (aHR) 2.23) and central nervous system atrophy (aHR, 27.79), markedly elevated all-cause mortality. Furthermore, extrapyramidal and movement disorders (aHR 2.16, p = 0.06) and demyelinating diseases of the central nervous system (aHR 6.36, p = 0.06) showed a trend toward increased mortality risk.

CONCLUSION

To the best of our knowledge, this is the first study from Central Asia exploring a large epilepsy cohort. The findings highlight the need for targeted interventions to address the growing burden of epilepsy, particularly among children, male sex, and those with neurological comorbities.

Mortality of Epilepsy in Chinese Populations: A Comprehensive Review

BACKGROUND

Premature mortality is a significant part of the epilepsy burden and may vary across populations, especially between high-income and lower- and middle-income countries. People with epilepsy in China are approximately a fifth of the global population with epilepsy. Previous studies were unlikely to represent the situation in China due to limitations in design, methods, sample size, follow-up time, and other inherent population heterogeneity.

SUMMARY

By summarising the evidence on the mortality characteristics in Chinese populations with epilepsy in the last 6 decades, we found a median mortality rate of 14.7 (6.8-74.4)/1,000 person-years and a median standardised mortality ratio (SMR) of 4.4 (2.6-12.9) in population-based studies, and a median mortality rate of 12.3 (9.5-101.5)/1,000 person-years and a median SMR of 3.0 (1.5-5.1) in hospital-based studies. Vascular diseases, complications of diabetes, and accidental injuries were the leading causes of death. Risk factors for mortality were reported as older age, male, longer duration, and higher frequency of seizures. Case fatality ratios of status epilepticus in adults were higher than in children, and both increased with follow-up time. Mortality in people with symptomatic epilepsy was high and varied across different primary diseases.

KEY MESSAGES

The highest mortality rate and sudden unexpected death in epilepsy (SUDEP) incidence were reported from the least developed areas in China. Accidental injuries were the most common causes of epilepsy-related deaths, while the incidence of SUDEP may be underestimated in Chinese populations. Further research is warranted to improve the understanding of premature mortality risk so that preventative measures can be introduced to improve the situation.

[Incidence of sudden death in epilepsy (SUDEP): update and limitations]

BACKGROUND

Sudden unexpected death in epilepsy (SUDEP) is in most cases probably due to a fatal complication of tonic-clonic seizures and plays a significant role in the premature mortality of individuals with epilepsy. The reported risks of SUDEP vary considerably depending on the study population, so that an up-dated systematic review of SUDEP incidence including most recent studies is required to improve the estimated SUDEP risk and the counseling of individuals with epilepsy.

OBJECTIVE

To provide an overview of the current research landscape concerning SUDEP incidence across different patient populations and discuss potential conclusions and existing limitations.

MATERIAL AND METHODS

A systematic literature review on SUDEP incidence was conducted in MEDLINE and EMBASE, supplemented by a manual search in June 2023. Out of a total of 3324 publications, 50 were reviewed for this study.

RESULTS

The analyzed studies showed significant heterogeneity concerning cohorts, study design and data sources. Studies conducted without specific criteria and relying on comprehensive registers indicated an incidence of 0.78-1.2 per 1000 patient-years. Research providing incidences across various age groups predominantly show an increase with age, peaking in middle age.

DISCUSSION

Due to varying methods of data collection and incidence calculation, comparing between studies is challenging. The association with age might be due to an underrepresentation of children, adolescents and patients over 60 years.

CONCLUSION

Considering all age groups and types of epilepsy it is estimated that about 1 in 1000 individuals with epilepsy dies of SUDEP annually. With an assumed epilepsy prevalence of 0.6% in Germany, this could lead to more than one SUDEP case daily. Standardization of research methods is essential to gain more profound insights.

Biomechanical Effects of Seizures on Cerebral Dynamics and Brain Stress

Epilepsy is one of the most common neurological disorders globally, affecting about 50 million people, with nearly 80% of those affected residing in low- and middle-income countries. It is characterized by recurrent seizures that result from abnormal electrical brain activity, with seizures varying widely in manifestation. The exploration of the biomechanical effects that seizures have on brain dynamics and stress levels is relevant for the development of more effective treatments and protective strategies. This study uses a blend of experimental data and computational simulations to assess the brain's physical response during seizures, particularly focusing on the behavior of cerebrospinal fluid and the resulting mechanical stresses on different brain regions. Notable findings show increases in stress, predominantly in the posterior gyri and brainstem, during seizures and an evidence of brain displacement relative to the skull. These observations suggest a dynamic and complex interaction between the brain and skull, with maximum shear stress regions demonstrating the limited yet essential protective role of the CSF. By providing a deeper understanding of the mechanical changes occurring during seizures, this research supports the goal of advancing diagnostic tools, informing more targeted treatment interventions, and guiding the creation of customized therapeutic strategies to enhance neurological care and protect against the adverse effects of seizures.

Psychiatric comorbidities in epilepsy: population co-occurrence, genetic correlations and causal effects

Background

Psychiatric comorbidities are common in patients with epilepsy. Reasons for the co-occurrence of psychiatric conditions and epilepsy remain poorly understood.

Aim

We aimed to triangulate the relationship between epilepsy and psychiatric conditions to determine the extent and possible origins of these conditions.

Methods

Using nationwide Swedish health registries, we quantified the lifetime prevalence of psychiatric disorders in patients with epilepsy. We then used summary data from genome-wide association studies to investigate whether the identified observational associations could be attributed to a shared underlying genetic aetiology using cross-trait linkage disequilibrium score regression. Finally, we assessed the potential bidirectional relationships using two-sample Mendelian randomisation.

Results

In a cohort of 7 628 495 individuals, we found that almost half of the 94 435 individuals diagnosed with epilepsy were also diagnosed with a psychiatric condition in their lifetime (adjusted lifetime prevalence, 44.09%; 95% confidence interval (CI) 43.78% to 44.39%). We found evidence for a genetic correlation between epilepsy and some neurodevelopmental and psychiatric conditions. For example, we observed a genetic correlation between epilepsy and attention-deficit/hyperactivity disorder (rg=0.18, 95% CI 0.09 to 0.27, p<0.001)-a correlation that was more pronounced in focal epilepsy (rg=0.23, 95% CI 0.09 to 0.36, p<0.001). Findings from Mendelian randomisation using common genetic variants did not support bidirectional effects between epilepsy and neurodevelopmental or psychiatric conditions.

Conclusions

Psychiatric comorbidities are common in patients with epilepsy. Genetic correlations may partially explain some comorbidities; however, there is little evidence of a bidirectional relationship between the genetic liability of epilepsy and psychiatric conditions. These findings highlight the need to understand the role of environmental factors or rare genetic variations in the origins of psychiatric comorbidities in epilepsy.

Seizing Off This Mortal Coil: A Matter of Epilepsy and Death

Premature Mortality and Causes of Death Among People With Epilepsy: A Nationwide Population-Based Incident Cohort Study Moon HJ, Lee H, Yoon D, Koo YS, Shin JY, Lee SY. Neurology. 2023;100(20): e2060-e2070. doi:10.1212/WNL.0000000000207212 . PMID: 36948594 ; PMCID: PMC10186245 Background and objectives: People with epilepsy (PWE) are at risk of premature death with considerable variability according to the study population. We aimed to estimate the risk and causes of death in PWE according to age, disease severity, disease course, comorbidities, and socioeconomic status in Korea. Methods: We conducted a nationwide population-based retrospective cohort study using the National Health Insurance database linked with the national death register. Newly treated PWE from 2008 to 2016 who were identified by antiseizure medication (ASM) prescriptions and diagnostic codes for epilepsy/seizure were included and observed until 2017. We assessed all-cause and cause-specific crude mortality rates and standardized mortality ratios (SMRs). Results: Among 138,998 PWE, 20,095 deaths were identified, and the mean follow-up period was 4.79 years. The SMR was 2.25 in the overall group of PWE, with a higher value in the younger age group at diagnosis and a shorter time interval after diagnosis. The SMR in the monotherapy group was 1.56, while that in the group with 4 or more ASMs was 4.93. PWE without any comorbidities had an SMR of 1.61. PWE who were rural residents had a higher SMR than those who were urban residents (2.47 vs 2.03, respectively). The causes of death among PWE were cerebrovascular disease (18.9%, SMR 4.50), malignant neoplasms outside the CNS (15.7%, SMR 1.37), malignant neoplasms of the CNS (6.7%, SMR 46.95), pneumonia (6.0%, SMR 2.08), and external causes (7.2%, SMR 2.17), including suicide (2.6%, SMR 2.07). Epilepsy itself and status epilepticus accounted for 1.9% of the overall death. The excess mortality associated with pneumonia and external causes was persistently high, whereas the excess mortality associated with malignancy and cerebrovascular diseases tended to decrease with increasing time since diagnosis. Discussion: This study showed excess mortality in PWE, even in those without comorbidities and those receiving monotherapy. Regional disparities and sustained risks of deaths from external causes over 10 years imply potential points of intervention. In addition to active control of seizures, education about injury prevention, monitoring for suicidal ideation, and efforts to improve accessibility to epilepsy care are all required to reduce mortality.